Does Self-Help Harm?

I love the BBC, but their online science and health articles have an unfortunate tendency to be, well, rubbish. At least, the headlines do. A while back I wrote about their proclamation that "Homeopathy 'eases cancer therapy'". The problem with that one was that the only treatments which worked turned out to not actually be homeopathic.

So when I saw the headline "Self-help 'makes you feel worse'", I suspected that whatever research they were reporting on might not have been about self-help at all. Call me a pessimist. But I was right. Go me. Bear with me, though, because the study in question raises some fascinating psychological issues.
The paper is Wood et al's Positive Self-Statements: Power for Some, Peril for Others. The authors aimed to study positive self-statements, the repetition of which is apparantly recommended by many self-help books. One example they give is "I’m powerful, I’m strong, and nothing in this world can stop me". I would hope no-one actually believes that because that would make them floridly manic, but youy get the gist. Now there can't be 92,000 books dedicated to telling people just to do that, so there's a little more to self help than that. But positive affirmations are indeed popular.

Wood et al note that repeating such positive statements might not make everyone feel better. It could have the opposite effect in some people. If you believe yourself to be, say, unloveable, then repeating a "positive" phrase, such as "I am loveable", might make you think to yourself "No I'm not really, I'm horrible...", and feel worse. People with low self-esteem, the people who are most likely to seek self-help, would seem to be most at risk of this.

To test whether such a negative effect in fact occured, they took some psychology undergraduates and told half of them to think to themselves "I am loveable" when they heard a bell ring, which happened every 15 seconds for 4 minutes. And as they predicted, the students who reported low self-esteem to begin with ended up feeling worse. Except, they didn't report "feeling" worse, rather they answered some questions in a more negative way:

Mayer and Hanson’s (1995) Association and Reasoning Scale (ARS), which includes questions such as, ‘‘What is the probability that a 30-year-old will be involved in a happy, loving romance?’’ Judgments tend to be congruent with mood, so optimistic answers suggest happy moods.

In a follow-up experiment, the authors tested the possiblity that the reason why the low-self-esteem group "felt" worse after the positive statements was that they felt themselves unable to succeed in the task - only thinking happy thoughts - and perceived themselves as failing:

‘‘If I’m supposed to think about how I’m lovable and I keep thinking about how I’m not lovable, the ways in which I’m not lovable must be important. I must not be very lovable . . . .’’

So they found that the negative effect of the statements was only present when the students were asked to ‘‘focus only on ways and times in which the statement ["I am loveable"] is true’’, and did not occur when they were "allowed" to focus on ways the statement ‘‘may be true of you and/or ways in which [it] may not be true of you.’’

Fair enough. But there's a crucial limitation with this study, and it's one which also looms large in the study of psychotherapy. The problem is that when people buy a self-help book and decide to start repeating positive statements to themselves, they are doing more than just thinking some words. They are, or at least they believe that they are, taking positive steps which have the power to change their lives. They're turning over a new leaf - taking matters into their own hands. It's change they can believe in. Yes, they can!

Now, this (ugh) "empowering" sense of acting to improve things could bring about all kinds of positive changes. In which case, self-help books might "work" even if the specific technqiues, taken in isolation, are useless or even harmful.

This is directly relevant to psychotherapy. Say you want to run a placebo-controlled trial of a certain kind of therapy in the treatment of depression. You recruit some depressed patients, flip some coins to randomize them to get therapy or placebo... but what "placebo" intervention do you use?

You might decide that the "empowering" feeling of doing something positive about your problems is a mere "placebo effect", so your control group should also experience it. In which case, they should be given some kind of meaningful therapy. Presumably it would have to be a different kind from the "real" therapy group, or it wouldn't be a trial, but then what do you use?

On the other hand, many psychotherapists would reply that this "placebo effect" is exactly what they spend a lot of time trying to produce - it's an integral part of the therapeutic process, and so the control group should not be given it. They should be given something much less involved, like non-specific "supporting talking", or nothing at all ("waiting list").

Now, this is an ongoing debate, and I'll be writing more about in the future, but the lesson is, whenever you read about a "placebo-controlled" trial of any psychotherapy, it's worth thinking about what the "placebo" was.

Apologies to Savage Chickens for "borrowing" the wonderful cartoon. I couldn't resist...

Wood, J., Elaine Perunovic, W., & Lee, J. (2009). Positive Self-Statements: Power for Some, Peril for Others Psychological Science DOI: 10.1111/j.1467-9280.2009.02370.x